“Knotted electrical wire with a glass tube at the top as a foreign body in a male urethra: a case report”

Abstract

Background

A large number of self-inflicted foreign bodies have been reported in the male urethra and urinary bladder. Polyembolokoilamania is a Greek derivative describing the behavioral phenomenon of inserting foreign objects into bodily orifices.

Case presentation

We report a 27-year-old unmarried male who presented the emergency department after inserting a knotted electrical wire with a glass tube at the top of his bladder. The patient admitted he inserted soft objects into his penis for pleasure, curiosity, feelings of emptiness, and the need for sexual excitement. A pelvic x-ray confirmed the presence of a knotted wire stump within the urinary bladder. Faced with these challenges, we tried utilizing a 7.5 F, 26-cm pediatric flexible cystoscope. Despite our best efforts, the tightness of the knot proved insurmountable. Under spinal anesthesia, a suprapubic cystotomy was performed, and the wire was untied and retrieved from the urinary bladder via the urethra.

Conclusion

When the urethra is too narrow for an adult cystoscope, a pediatric cystoscope can be a considerable intervention option.

Background

The discovery of a genitourinary foreign body is uncommon, although there has been an increase in the number of occurrences in recent decades [1]. Urologists have long been grappling with this problem, as it presents a considerable difficulty in terms of both diagnosis and treatment [2]. The etiopathogenesis of urinary bladder foreign bodies typically occurs through self-insertion, iatrogenic processes, or migration from nearby organs. This can occur in individuals without psychiatric conditions who have specific fetishes [3].

Polyembolokoilamania is a term derived from Greek that refers to the behavioral phenomena of inserting foreign objects into bodily orifices [4]. The range of objects reported includes hairpin wires, fish hooks, and bits of Foley catheters to intrauterine contraceptive devices, surgical gauze, shattered portions of endoscopic tools, rubber bands, hairballs, metal rods, telephonic cables, orthopedic screws, home batteries, and more [5,6,7]. There is a significant majority of male patients [5, 6, 8, 9]. Most patients present late for admission, increasing the likelihood of severe local or systemic problems that may have already occurred. Frequent grievances reported by these patients consist of dysuria, urine retention, lower abdomen pain, hematuria, urethral discharge, and fever. Smaller, less affected objects can lead to enduring chronic symptoms such as recurrent urinary tract infections (UTIs). Urinary stones and urosepsis may occasionally arise [5]. In Iran, the infrequency of reporting these situations is attributed to their taboo status, which hinders effective problem management among clinicians. Thus, we provide a case of a 27-year-old single male who sought medical attention at the emergency department after self-inserting a knotted electrical wire with a glass tube at the top into his bladder.

Case presentation

The patient was a 27-year-old unmarried Iranian male who was employed. He came from an Iranian family with a lower middle socio-economic status. He was admitted to the emergency department after inserting a knotted electrical wire with a glass tube at the top into his bladder through the urethra. There was no record of any childhood trauma, bullying, abuse, substance use, or a distinct psychotic or affective episode. He consistently denied having any history of substance use. There was an absence of any psychiatric or hereditary disorder in the family history. The comprehensive assessment revealed that he exhibited normal vital signs. The physical examination revealed tenderness in the suprapubic region. The foreign body appeared impacted and could not be manipulated. A pelvic x-ray showed the existence of a tangled wire fragment inside the urinary bladder (Fig. 1).

Fig. 1

Plain pelvic X-Ray: It shows a knotted electrical wire with a glass tube at the top stump within the urinary bladder.

Management

Initially, we employed the standard endoscopic method, which includes removing the foreign body with grasping forceps of an adult cystoscope. The knot at the end of the foreign wire was three times the diameter of the urethra, presenting a significant hurdle. This approach failed due to potential risks, including urinary tract perforation and complications that could necessitate urethroplasty with complex closure methods. Faced with these challenges, we tried utilizing a 7.5 F, 26-cm pediatric flexible cystoscope. Utilizing pediatric cystoscopes minimizes trauma while maximizing visibility and control during the procedure. At first, the cystoscope was inserted to grasp the foreign object securely. Then, the cystoscope allowed for direct access to untie the knot. Despite our best efforts, the tightness of the knot proved insurmountable. To prevent more damage to the urethra, we decided to perform an open cystotomy. Antibiotics were given as a preventive measure based on the patterns of bacterial sensitivity. A suprapubic cystotomy was performed under spinal anesthesia to extract the wire from the urinary bladder through the urethra (Fig. 2). The wound was sutured, and a urethral catheter was inserted and remained in situ. After three days, the indwelling catheter was extracted, and the patient was discharged home in good condition. Following the treatment, the patient experienced no complications throughout his recovery and did not report any additional issues related to lower urinary tract symptoms or impotence.

Following the surgical procedure, a comprehensive medical history was obtained at the psychiatry clinic due to sexually problematic behavior characterized by the act of inserting various objects into the urethra during masturbation. The individual reported feelings of despair and the inability to experience pleasure. He denied inserting items into any of his other bodily orifices. He had started masturbating when he was in his 20s. He began to participate in the act of entering objects via the urethra, with the expectation that it would provide him the highest level of satisfaction. The individual confessed to inserting soft objects inside his penis due to his curiosity and because he was experiencing a sense of emptiness and seeking sexual excitation. Initially, he acquired the habit of inserting small objects and gradually progressed to experimenting with larger objects over time.

Fig. 2

Intra-operative view through a suprapubic cystotomy: A suprapubic cystotomy was performed under spinal anesthesia to extract the wire from the urine bladder through the urethra.

Discussion and conclusions

A significant prevalence of self-inserted foreign objects has been documented in the male urethra and urinary bladder [10,11,12,13,14]. The assortment of these items is truly remarkable, encompassing piercing and cutting devices (such as needles, pencils, and wires), wire-like objects (such as cables and rubber tubes), components of animals (bones), as well as plants and vegetables (such as hay and cucumbers), fluids (such as glue), and powders (such as cocaine) [10]. The clinical presentation of this condition can range from having no symptoms to experiencing swelling of the external genitalia, pain or dtifficulty during urination, a weak urinary stream or inability to urinate, and the presence of red or pus-filled discharge from the urethra. Additionally, there may be an increased risk of developing a urinary tract infection that spreads upwards from the urethra [10, 11]. Bladder stones sometimes develop in chronic cases [15]. The conventional method for identifying and evaluating foreign bodies in the bladder uses KUB and cystoscopy. In certain circumstances, Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) can also be helpful [5]. Multiple therapeutic modalities have been documented for managing foreign bodies of the bladder, including endoscopic, percutaneous, open, and laparoscopic approaches. If the surgeon determines that the object can be extracted without causing any harm to the urethra, they should initially attempt the endoscopic approach [11]. The extraction method depends on the item’s size and movement within the urinary bladder [16]. For certain patients, removing a foreign object from the bladder might be challenging, and it may be necessary to perform open surgery [1]. Patients who have intentionally inserted foreign objects into their urethra or urinary bladder should get a psychological examination. This is because there is a significant prevalence of psychiatric disorders, mental retardation, and dementia in these individuals. Doing this decreases the likelihood of the problem reoccurring [17, 18]. Mibang et al. reported a case of ampoule glass inserted into the bladder. In their case, the usual endoscopic approach was not used due to the possibility of glass breakage, and their problem was not the size of the ampoule glass. They removed the glass using an open approach [19]. In another case, Faridi et al. removed a large stone trapped in the bladder using an open cystotomy [20]. Our patient had used a top Headspace lidocaine tube. He had first carefully cut off the closed end of the tube, then passed a wire through it and tied the end of the wire.

In this case, we report a 27-year-old unmarried male who presented the emergency department after inserting a knotted electrical wire with a glass tube at the top of his bladder. This act was motivated by sexual enjoyment or curiosity. In this case, we encountered difficulty inserting the adult cystoscope into the urethra, which contained a wire, prompting us to utilize a smaller pediatric cystoscope instead. This alternative approach allowed us to navigate the urethra effectively and reach the target area with a grasper to attempt to untie the wire knot. However, the knot proved too tight to untie despite successfully reaching the location. This situation highlights that when the urethra is too narrow for an adult cystoscope, a pediatric cystoscope can serve as a considerable option for intervention. By exploring these non-invasive alternatives, we can provide a more comprehensive and patient-centered approach to care, ultimately leading to better overall health outcomes and patient satisfaction. Consequently, a suprapubic cystotomy procedure was performed to untie and retrieve the wire from the urinary bladder through the urethra. We also found that if the diameter of the trapped foreign body is up to two times larger than the diameter of the urethra, it can be self-removed or by conventional endoscopic methods. However, in cases where the diameter of the foreign body is three times larger, it can only be removed by open methods.